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Transitional Care

​​​​​​​​​​​​We ensure the seamless continuity of care for patients as they move from our hospital to various community settings.​

 
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​About Us​​​​

​We are committed to ensuring seamless continuity of care for patients as they move from our hospital to various community settings, including their own homes, nursing homes, and beyond.

​This is achieved through a collaborative and multi-disciplinary team consisting of doctors, nurses, allied health professionals, medical social workers, pharmacists, virtual care specialists, and administrative staff.


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Our Services​​​


Transitional Care supports an array of services carefully designed to deliver secure and prompt interventions. Working hand in hand with our community nurses and allied health teams, we provide comprehensive medical and nursing care, physical therapy, psychosocial support, and case management.​​ Our commitment extends to providing patients with a range of seamless, responsive, and high-quality care options beyond the hospital, addressing their multiple co-morbidities or complex medical/nursing care needs.

​The focus is on a comprehensive approach, encompassing clinical assessment, treatment, nursing procedures, rehabilitation, medication management, patient and caregiver education, psychosocial support, follow-up care, and meticulous care coordination. ​​​This approach significantly reduces the risk of complications, unplanned readmissions, and unnecessary emergency department visits.​

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Hospital to Home (H2H) is a comprehensive programme designed to ensure a safe and timely transition for discharged patients from the hospital to their homes. The programme offers multi-disciplinary care support tailored to the severity and specific needs of each patient.

A key component of the programme is to facilitate seamless care for patients transitioning from the hospital to the community. This involves receiving clinical care in their homes, supported by a diverse team of healthcare professionals, including doctors, nurses, allied health experts, dieticians, pharmacists, medical social workers, and virtual care specialists.

Objectives

  • Facilitate patients’ seamless care transition from hospital to the community

  • ​Support patients as they continue their post-discharge recovery in the comfort of their homes

  • Hand over to appropriate community provider for continuation of care if long-term follow up is required


Within Nursing Home Supportive Care (NHSC), we offer services tailored to the unique needs and readiness of each Nursing Home. Alongside End-of-Life care and Advance Care Planning (ACP), we provide additional support through collaborative nursing efforts and specialis​ed assistance in geriatric and psychiatric care.

Our doctors and community nurses collaborate closely with Nursing Home healthcare professionals. Together, we proactively screen and identify residents in need of palliative care, initiate crucial goals of care conversations, and co-manage residents through regular case discussions, reviews, and tele-collaboration.

We also offer capability building through training sessions and ad-hoc tele-support to empower Nursing Home care teams in managing complex cases.

Objectives

  • Develop Nursing Home's capability in the areas of palliative cand geriatric care

  • Build a culture of ACP in Nursing Homes

  • Enable residents to access palliative care in a timely and integrated manner

  • Honour residents' preferences in to managing their care, particul​arly at end-of-life​



Woodlands Health partners the following Nursing Homes:

  • Woodlands Care Home

  • Ren Ci @ Woodlands

  • Orange Valley @ Marsiling

  • Man Fut Tong Nursing Home



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